Inspection on 22/02/07 for Victoria Oaklands

This inspection was carried out on 22nd February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Oaklands 10/03/08

Victoria Oaklands 05/12/05

Victoria Oaklands 05/01/05

Victoria Oaklands 06/08/04

Victoria Oaklands 20/08/02

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria Oaklands 39 Dyke Road Avenue Hove East Sussex BN3 6PA Lead Inspector Linda Boereboom Key Unannounced Inspection 22nd February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Oaklands Address 39 Dyke Road Avenue Hove East Sussex BN3 6PA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273-330806 01273-881627 Victoria Nursing Homes Limited Mrs Sara Spiers Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22), Physical disability (22), Terminally ill (22) of places Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-two (22) Service users must be older people aged sixty-five (65) years or over on admission Service users may have a physical disability Date of last inspection 5th December 2005 Brief Description of the Service: Victoria Oaklands, 39 Dyke Road Avenue is a large detached house in a residential area of Brighton and Hove. It is set back from the road with a sweeping drive that has parking for up to ten cars. The home has a beautiful and secluded garden at the back that is accessible for wheelchair users and provides lovely views for residents who have rooms at the rear of the home. All rooms in the home have a view and are very comfortable and pleasant. There is a passenger lift that serves both floors. The home is registered for 22 residents who fall into the categories of old age, physical disability, and terminal illness. Victoria Oaklands houses the central kitchen for all the homes, providing hot meals daily that are transported at lunchtime and served individually by designated staff. As with the other homes in the Victoria Group, Victoria Oaklands has the Quest for Quality Award. In the garden of the home are the training rooms for staff, and the central equipment store for the Victoria Group. All outbuildings are within keeping with the main building. The Number 27 and 27a buses stop nearby and run between the main shopping area of Brighton, and Brighton mainline station. There is consistency of care, administration and recruitment throughout all the homes in the Victoria Group. The Registered Providers and their staff are to be congratulated on the efforts made to ensure that service users receive a good quality of care in very pleasant and welcoming surroundings. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Victoria Oaklands will be referred to as ‘residents’. This inspection was unannounced and Mrs Sara Spiers, the home’s Registered Manager, assisted the Inspector. The inspection took place over a period of 5.5 hours and during that time the Inspector was able to tour the premises and speak with seven of the home’s residents. Two of the care staff were interviewed by the Inspector and later she was able to speak with other care staff whilst they were working in the home. The Inspector also looked at individual resident’s records and the home’s administrative process. Staff records had been assessed prior to the inspection when the Inspector spoke with four trained nursing staff who work throughout the Victoria Group of homes on either day or night duty, this was done at the Victoria Head Office. Unfortunately the Inspector did not meet any resident’s relatives during the inspection but did leave telephone messages for four relatives offering them the opportunity to make contact should they so wish. One relative contacted the Inspector immediately and said the staff were ‘excellent, kind, friendly and caring ’, that the Registered Manager was good at getting everyone organised, and the home was ‘brilliant’. The cost of care in the home varies from £595 to £795 a week; items not covered by the fee include hairdressing, chiropody, some incontinent products, toiletries and magazines. Ten resident surveys and care staff surveys were sent out randomly by the Commission for Social Care Inspection prior to the inspection and at the time of writing this report four resident surveys had been returned. Comments made in the surveys and to the Inspector during the Inspection have been reflected throughout this report. The Inspector discussed the outcome of the inspection and the requirements resulting from it with the Registered Manager, Registered Providers and the Director of Nursing Services at the end of the day. The Inspector would like to thank Mrs Spiers and the staff for their helpfulness and hospitality and for making the inspection a pleasant and enjoyable experience. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 7 Few requirements have been made in this report. Those that have were discussed in full at the end of the inspection and relate to the training and updating of staff in the protection of vulnerable adults its different levels of investigation, and training in the new fire safety legislation. Policies and procedures require review and although the staff take care in the administration of medication the process used needs to be reviewed regularly. All standards have been scored as being met because over all practices are good. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a statement of purpose and service user guide that is available for residents and relatives; in addition the home ensures the latest inspection report is also available. There is a procedure in place for residents to be properly assessed before admission and residents are invited to visit the home before making a decision to move in. The statement of purpose requires updating in some areas. EVIDENCE: Victoria Oaklands has sufficient information for residents and their relatives to read that is available in the home with the latest inspection report. The Director of Nursing Services takes responsibility for all the pre-admission Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 10 assessments and at that time she verbally gives information about the home and offers prospective residents written information. This system is consistent throughout all the Victoria Homes. The Inspector requested that the home’s statement of purpose be brought up to date with appropriate information being included on the qualifications of care staff i.e. NVQ achieved or being undertaken, explanation that the home does not provide outings for residents, and the identification of medical conditions that are not accepted in the home. The Inspector noted that the new address of the CSCI at the Maidstone office had been added to the information. Care needs assessments undertaken by the Director of Nursing Services for the Victoria Group act as a basis for the ongoing care planning. The qualified nursing staff provide any specialised care for residents should it be necessary however care staff are trained to manage catheters and to understand any specialised needs that a resident may have. Care staff do not undertake any invasive nursing procedures. The home rarely accepts emergencies however should one take place the senior staff were aware of the need to comply with standard 5.3. Trial visits to the home are encouraged and prospective residents are encouraged to visit the home for either a meal or afternoon tea and to meet the residents and staff prior to making the decision to move in, if they are unable to do so their relatives or friend’s are invited to visit on their behalf. The home does not have any specific intermediate care beds however some residents do come from hospital to Victoria Oaklands for a short while to gain strength and confidence prior to returning home. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home delivers a good quality of care that is well documented. All residents’ have an individual plan of care that is well maintained. Trained staff take care with the administration of medication, however care staff require training in medication and it’s uses. Residents are treated with respect and their privacy acknowledged. The home is empathetic to the care of residents nearing the end of life. EVIDENCE: All residents have a care plan that is based on the initial pre-admission assessment undertaken by the Director of Nursing Services for the Victoria Group. Care plans are looked at daily as a matter of course with an exchange of information between staff during the handover between each shift. Formal reviews of care take place monthly for those residents who are in a stable Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 12 condition, whilst those who are unwell are reviewed as often as their condition requires. The Inspector looked at care plans and found them to provide clear indication of the nursing and general needs of each resident, including information about visits from healthcare professionals. The Inspector also looked at records in the home relating to regular assessments including wound care, blood pressure and weight monitoring. Residents spoken with said they are regularly weighed and the Registered Manager confirmed that appropriate weighing equipment is shared between the homes within the Victoria Group. The Registered Manager told the Inspector she plans to set up her own training in addition to that provided by the trainer for the Victoria Group to promote knowledge and good practice within the home. She had also instigated regular eye and dental checks for residents since becoming Manager. All residents spoken with by the Inspector said they were pleased with the care they received and confirmed they are monitored for progress including regular blood tests. One resident told the Inspector ‘If you have to be in a nursing home, this one is pretty good!’ and another said, ‘I feel well looked after, I really, really do’. Victoria Oaklands was the last home inspected in the Victoria group and the method of administration of medication was found to be consistent throughout. Requirements were made in the other reports relating to the training of staff in medication and its uses, as untrained care staff were regularly asked to check medication, which included controlled medication. This was also the case in Victoria Oaklands. The Inspector was told that the in-house trainer for the Victoria Group was addressing this issue and dates were arranged for staff to attend training. In addition a potting up method of administration of medication was also used throughout all homes in the group and conversation with all Registered Managers, the Director of Nursing Services and the Registered Providers took place about the safety and security of this practice. It was decided by the Senior Management of the Victoria Group to continue with the potting up method and confirmation of this, in writing, was given to the Inspector on the day of inspection that will be held on each Victoria Home’s service file. The Inspector also discussed the possibility of having a specific lockable medication wall unit in each room for medication as the Senior Management preferred to avoid the use of medication trolley’s however this was decided against. A requirement will appear in this report requesting the methods of administration of medication are regularly reviewed to remain in line with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS’ and are reflected in the Regulation 26 monthly reports undertaken by the Registered Provider. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 13 All residents and relatives spoken with by the Inspector said they found staff to be respectful and kind. Residents have their own telephone lines and when asked said they open their own post and are able to see visitors in their own room’s or the communal sitting room. The Inspector noted that care staff knocked on doors and observed they had a pleasant, friendly attitude towards residents and colleagues. The Inspector spoke with the Registered Manager about the emotional and care needs of residents nearing the end of life. The Registered Manager told the Inspector that residents are able to stay in the home and in their own rooms as long as their care needs can be fully met. Relatives are invited to stay with the resident sharing the home’s facilities. The home also works closely with the local Martletts Hospice who provide a nursing team for advice and support and some specialised training in palliative care. She said counselling was available for staff and confirmed that overall staff support each other. Two members of the care staff told the Inspector they would always try not to let anyone die alone and examples were given of extra hours being worked to make sure residents were supported throughout. Independently the Registered Manager and care staff told the Inspector that the ethos of the home is to provide an environment as near to the resident’s own home as possible. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are encouraged to maintain contact with family and friends, who are made welcome and encouraged to visit. The Activities Coordinator provides regular activities for those residents who wish to participate and care staff are pro-active in providing residents with a social environment that they enjoy. Residents have choice in their everyday lives and benefit from a varied and balanced diet. EVIDENCE: There is an Activities Co-ordinator who works for the Victoria Group and visits each home at least once, if not twice weekly. During these visits she organises group activities i.e. bingo, quizzes, painting, and making cards and decorations (at festive times of year). If residents do not want to participate she will visit Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 15 them on a one to one basis to read to them or chat. In addition the Registered Manager told the Inspector that someone occasionally visits the home for singing and story telling. The staff at Victoria Oaklands are all very involved in providing activities for residents. At Christmas the home had a Victorian theme and staff ran a Christmas bazaar. They also contributed personally to give each resident a Christmas stocking. Staff also organise a summer garden party with line dancing, work together to give birthday cards, presents and cakes to each resident and support relatives if they wish to hold family parties. The Inspector was shown albums of photographs made by staff for the residents to look back over celebrations shared in the home. In addition the Registered Manager told the Inspector she would like to start residents outings and is looking into this for the Spring and Summer 2007. The Deputy Manager and other care staff want to support this. The Inspector and Registered Manager discussed the necessity and importance of all residents being risk assessed to participate in the outings; should outings become available information about them needs to be included in the home’s individual statement of purpose. Visitors are made welcome in the home, residents and relatives confirmed this. They also said meals and snacks are offered to them. A visitors’ book, used daily, gives a record of all visitors to the home. The Registered Manager said there are no fixed visiting times but relatives are asked to avoid visiting first thing in the morning if at all possible. Meals in Victoria Oaklands remain well balanced, good in quality and sufficient in quantity. Everyone spoken with during the inspection process confirmed this. At the time of the inspection a number residents were eating their lunch together in the dining room whilst some preferred to eat in their own room’s. The main kitchen is at Victoria Oaklands and food is delivered twice daily for lunch and supper to other homes in the group. Menus are faxed to the homes on the previous day for residents to make their choice. Records of meals eaten are kept for six weeks. The pre-inspection questionnaire returned to the Inspector showed a rolling programme of menus. One resident’s survey returned to the Inspector read, ‘They are very good at providing something I like if what is offered on the daily menu is not to my liking’, another said ‘I have a small appetite but am able to supplement this with lots of milky drinks’. Only one person commented that there should be more variation in the meals provided whilst another wrote ‘I am helped a lot to have the food that is best for my condition and sometimes different from the daily menu’. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are protected by the home’s attitude towards complaints and staff have an awareness of protecting staff from potential abuse. Residents are able to participate in the process of voting if they so wish and information on advocacy services is made available to them if necessary. EVIDENCE: The pre-inspection questionnaire sent to the home prior to the inspection was returned to CSCI saying there had been no complaints and no incidences reported since the last inspection. The Registered Manager was aware of the need to record all concerns and complaints no matter how minor. A complaints log is used by the home that is familiar to all the homes in the group. In addition there is a complaints book left in the entrance hall for anyone to use if they wish although staff, residents and relatives all said they would feel confident in going to the Registered Manager if they were not happy about something. One resident wrote in a survey returned to the CSCI, ‘I have never needed to make a complaint so I wouldn’t know where to start but I would speak to the matron (Registered Manager) as my first port of call’. All other residents’ surveys confirmed they would know how to make a complaint. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 17 Residents are encouraged to use the postal voting system. Should a resident require an advocacy service in the absence of a friend or relatives, the Registered Manager said they would be referred to Brighton and Hove Social Care and Health Department for assistance. Prior to the inspection the Inspector spoke with senior staff working throughout the Victoria Homes about the protection of vulnerable adults and although they showed knowledge of the process not all fully understood it. Following inspection of other homes in the Victoria Group, The Inspector spoke with the Registered Providers and they agreed to address the issue as a matter of urgency with the new Trainer who started in post in January 2007, however as appropriate training had not taken place a requirement will appear in this report with a revised date of 15 March 2007. The Director of Nursing Services told the Inspector that the trainer for the Victoria Group would be doing the updated training on the day following the inspection. The Inspector did note that the minutes of the last Older Peoples Care and Assessment team meeting relating to adult protection and held by Brighton and Hove City Council was available in the office at Victoria Oaklands along with the revised flow cart for the adult protection procedure. Care staff spoken with by the Inspector in Victoria Oaklands showed a common sense approach to the protection of vulnerable adults and were very clear of their role and to whom to report, however they did need confirmation of the latest local guidelines on how the different levels of abuse are investigated. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20,21,22,23,24,25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance team for the Victoria group of homes make sure that attention is paid to any work, inside or out to maintain the safety and comfort of the residents and staff. The home has sufficient lavatories and washing facilities and each resident has a room that suits their individual needs. The home is kept clean and tidy and is well equipped with specialist equipment to maximise the independence of residents. EVIDENCE: Since the last inspection, there has been on-going redecoration within the home and one shower room had been retiled on the walls and floor. This was Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 19 entered on the pre-inspection questionnaire and confirmed by the Registered Manager. Victoria Oaklands has twenty single rooms; this includes double rooms currently inhabited by one resident. All have ensuite facilities. In addition there are toilets available throughout the home and pleasant communal rooms i.e. a dining room and sitting room both with views over the garden. The Victoria Group has an equipment store based at Victoria Oaklands for any extra aids, adaptations or specialised equipment. The home at the time of inspection was well equipped for the current residents. Resident’s going home would be referred to the Older People’s Care and Assessment Team at Brighton and Hove Council to make sure they received any equipment necessary. All residents have lockable facilities for their personal items of value and private papers. Personal laundry is undertaken in the home for which industrial machines are used. The laundry is situated away from the kitchen area. Heavy laundry is undertaken at another home in the Victoria Group. On the day of inspection the home was clean, tidy and organised. Residents confirmed their rooms were cleaned each day and that the cleaner was very helpful. Surveys returned to the Inspector all stated that the home is kept fresh and clean with one resident saying how impressed they were by the cleanliness in the home. Staff wear suitable protective clothing for the tasks they undertake and when spoken to confirmed that gloves, protective footwear and aprons for the kitchen and personal care are readily available. Following the inspection the Inspector spoke with the Registered Manager about the care of residents with infectious diseases and the promotion of a hygienic environment. The Inspector said the home could if they wanted, offer cleanable flooring instead of carpet in a resident’s room as long as the resident or his advocate was in agreement. At the time of inspection the home did not accept residents with clostridium difficile although the Director of Nursing Services did tell the Inspector, Registered Manager and Registered Providers she would accept residents with MRSA. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practice is thorough and protects residents as far as it is able. Care staff undertake mandatory training in addition to being offered NVQ training thus ensuring they are competent in the work they do and care they offer to residents. On the day of inspection the home appeared to be adequately staffed. EVIDENCE: On the day of inspection the home appeared to be adequately staffed. Residents said their call bells were answered quickly and in the majority of cases staff spent time talking to them as well as providing care. The Inspector spoke with the Registered Manager about staffing levels in the home and found that there was always a qualified nurse on duty who was supported by care staff. Each morning, in addition to the Registered Manager or qualified nurse in charge were four care staff, and each afternoon two care staff with the Registered Manager on duty and at night one trained member of staff and one care staff. The Registered Manager said that when a resident Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 21 had increased care needs or a new resident was expected extra staff were available from the Victoria care staff bank. The home also had two chefs and one server on duty as the kitchen at Victoria Oaklands provides cooked meals for all the homes in the group. Care staff told the Inspector they received induction training and shadowed existing staff with more experience prior to working alone. The Victoria group has a new in-house trainer in post who will be taking responsibility for staff mandatory training. At the time of inspection the Registered Manager was aware that the NVQ (National vocational qualification) level 2 certificate, had not been achieved by 50 of the care team. The Inspector looked at recruitment files prior to the inspection and found that a thorough system was in place. All staff had contracts of employment, job descriptions, undertook trial shifts and shadowing of experienced staff and received induction and mandatory training which included three days training a year. In addition all had been CRB (Criminal Records Bureau) checked. They were also offered the opportunity to undertake NVQ 2 once they had passed through their probationary period and shown a commitment to working for the Victoria Group of homes. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,24,25,36,37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the outcomes for residents’ are good. The home has systems in place to ensure it runs smoothly and residents are safeguarded by accounting and financial procedures. Residents and staff are protected by the home’s attitude to health and safety however the home needs to review its policies and procedures to accommodate the new fire safety legislation. EVIDENCE: Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 23 The requirement made in the last report relating to the keeping of maintenance records up to date had been addressed. The Registered Manager of Victoria Oaklands is a qualified Registered General Nurse and has worked in the home since February 2006; she was registered with the CSCI as Manager later in the same year. She has a qualification in management and five years experience specifically in the care and needs of the elderly. The Deputy Manager has many years experience working in the Victoria group of homes and is also a qualified nurse. Through talking to residents, staff and relatives the Inspector concluded that leadership in the home was open, positive and inclusive with the Registered Providers making regular visits to ensure good communication and the Registered Manager and senior staff working alongside care staff to promote a good standard of care. Residents and staff were made aware of the unannounced inspection taking place and the Registered Manager was helpful to the Inspector arranging for relatives to be contacted by telephone and staff to be interviewed. Surveys returned to the Inspector all stated that residents did not want to see the Inspector on the day of inspection. The Victoria Group of homes each have the Quest for Quality Award which involves undertaking effective quality assurance and quality monitoring checks on the home however the Inspector was told that the providers were in the process of changing the organisation used to assist them in ensuring quality therefore the certificate will not be continued after March 2007. The financial procedures and accounting systems for Victoria Oaklands are managed from the head Office of the Victoria Group, however regular meetings with the Providers ensures that any specific equipment or refurbishments, or extra staffing required could be discussed. The home does not get involved with resident’s finances and any purchases made from the petty cash allowance on behalf of residents are invoiced to them individually at the end of each month. The home has policies and procedures in place to maintain a safe environment and the Director of Nursing Services takes responsibility for maintaining them. The pre-inspection questionnaire stated that all policies had been reviewed last in February 2006; therefore these will need reviewing again as soon as possible. All staff are trained in moving and handling, food and hygiene, infection control and fire safety. Care staff confirmed this during conversation with the Inspector, who at the same time noted that staff required updating in the new fire safety legislation. There are records of all maintenance and servicing to gas and electrical installations and the water systems are checked for compliance with legionella regulations; the pre-inspection questionnaire sent to the CSCI supported this. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 24 During the inspection it was confirmed by staff that they have regular staff meetings and attend regular supervision on a one to one basis. They also confirmed having a yearly appraisal. The Registered Manager said she attended monthly matrons meetings for the Registered Managers within the Victoria group. Accidents and injuries are recorded and staff are aware of the need to report all communicable diseases to the Environmental Health Department at Lewes. As the home does not accept residents who are known to have clostridium difficile, this information should be incorporated in the homes statement of purpose to make sure relatives and prospective residents are aware of the situation. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1) Requirement The statement of purpose to reflect the following: Standard 13: whether or not outings are provided for residents. Standard 27: The qualifications of care staff and those undertaking NVQ2 or 3. Standard 38: that the home does not admit residents suffering from Clostridium Difficile. 2 OP9 Schedule3 (2)13(2) The home to regularly review the 31/03/07 methods of administration of medication to remain in line with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS. The Registered Provider to include the administration of medication when undertaking monthly Regulation 26 reports on the home and others within the Victoria Group. Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 27 Timescale for action 31/03/07 3 OP18 13(6) All senior nursing staff to receive updated training in the protection of vulnerable adults to include the different levels of investigation. All care staff to be trained on the latest Brighton and Hove Council guidelines for the protection of vulnerable adults to give information on how different levels are investigated. Policies and Procedures for the home to be reviewed (last done in February 2006). 15/03/07 4 OP18 13(6) 31/03/07 5 OP33 24(1)ab 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria Oaklands DS0000014072.V324740.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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